The Corona Virus Disease (COVID-19) sparked a global public health crisis that acted as a catalyst for the uptake of online education. As lockdown and social distancing measures were implemented around the globe, 46 countries on five different continents announced school closures to contain the spread of COVID-19 as of March 12, 2020. The rest of the world followed soon after. Class Central, the world’s top search engine for online courses, has seen a huge surge in traffic and Coursera, the world’s largest massive online open course (MOOC) provider, announced that it was offering free online courses in response to COVID-19 [10].
Despite being the first place to be hit by COVID-19, China has enacted a robust centralized epidemic response system, as the authorities battled to understand and contain the new pathogen. Particularly in the wake of the pandemic and in part due to the Zero-COVID policy, the already growing ed-tech and e-learning industry in China surged to fill in the demand for online education. Universities canceled all in-person classes and switched to virtual classrooms as mandated by the “disrupted classes, undisrupted learning” directive of the Ministry of Education [11]. In April 2020, China launched two MOOC platforms - XuetangX Global and iCourse International - and provided distant e-learning solutions to international learners.
As the world’s largest healthcare system is facing the impending consequences of demographic decline and an ageing population, the “Healthy China 2030” initiative was issued and set the education of healthcare professionals at the forefront of this long-term national strategic plan [12]. The number of higher clinical medicine graduates has steadily increased, with an average annual growth rate of 8.2% between 2002 and 2018 [13].
Although relevant before the outbreak, the use of eL as avenue for vascular surgery training has grown exponentially during the pandemic period [14, 15]. The EL-COVID study is the largest international survey to date that addressed the utility and overall adoption of e-learning in the international vascular surgery community during the COVID 19 pandemic and complements the limited, previously reported data [4, 5, 15]. Although particularly insightful, there are limited pre-pandemic data to compare our findings.
In our subgroup analysis of the EL-COVID registry, the Chinese vascular surgeons expressed the same interest in online activities as their counterparts, but these eL opportunities have been mostly international. National and international attendance has been positively correlated with proper accreditation (CME points/certificate), which seems to particularly incentivize Chinese physicians, as they are mandated to collect 25 hours of CME credits per year [16]. Furthermore, the research-oriented physician evaluation system exerts overemphasis on scientific activities, this being the main criterion for professional promotion and may indirectly pertain to the observed preference for accredited e-learning opportunities.
Attendance at national e-learning activities was significantly lower in PCR than in the rest of the nations, despite the fact that most of them were awarded an official accreditation. The concept of continuing medical education (CME) was introduced to China in the early 1980s and has since undergone systematic improvement. However, CME activities lacked legal framework and struggled with inconsistencies in form and content for many years [17], which may account for the observed low participation at national online activities. In 2008, the Ministry of Education established the Working Committee for the Accreditation of Medical Education (WCAME), the only agency to accredit medical education programs in China. In 2020, the World Federation for Medical Education (WFME) has recognized WCAME as accreditation body, signaling that the quality of China’s standards in medical education and accreditation mechanisms has reached an appropriate and rigorous standard [18].
The demographics in PRC differed significantly to that of the global survey cohort. Chinese participants were mainly senior surgeons and male, with junior colleagues and women being significantly underrepresented.
Although there have been many studies on gender inequality in surgery worldwide, there is little to none published literature in China. The World Health Organization reports that the surgical profession is male dominated [19]. According to the Chinese College of Surgeons’ “Investigation Report on the Practice Status of Chinese Female Surgeons (2019)”, the proportion of female surgeons is increasing, but still only comprises 6.04% of Chinese surgeons, and most of them are residents and attending physicians[20]. Traditional family values make it difficult for Chinese women to exchange the responsibilities of housework, children, and elderly care to those of the professional life. Furthermore, gender bias and reported violence against medical doctors in large hospitals [21] have deterred women from pursuing a surgical career. During the training period in China, it is common for trainees to work for 60–70 h per week, far exceeding the expected work hours (40 h per week). Additionally, the mandatory retirement age is 55 for women and 60 for men. Increased awareness, adopting inclusive measures and eradicating systemic barriers are necessary to close the gender gap in vascular surgery and to address the impeding workforce shortages.
Trainees and vascular surgeons with < 5 years of practice/fellows were underrepresented in the Chinese cohort (27.52% vs. 73.62%, p < 0.0001), sparking heated debate over access to relevant networking platforms and the percentage of professional opportunities that transpire to the level of junior colleagues. Such a hypothesis warrants however further insight.
The Chinese participants were informed of upcoming eL events through So.Me. or by actively researching what eL activities are available. The role of the national society in information dissemination was underrepresented and this is an aspect that the Chinese Medical Association and the local vascular institutions may consider addressing.
Chinese colleagues could not attend eL activities mainly due to lack of time and increased workload - a finding that is consistent throughout the EL-COVID analysis, as expected during the time of the pandemic. Chinese employees attending eL activities received less support when compared to the international cohort. Enabling protected/allocated time or educational leave would increase the attendance of eL activities, subsequently enhancing the professional skills and knowledge of vascular surgeons and trainees, as well as further improving patient care.
A comparison between PRC and international results has to be viewed with caution, as the reported data are derived from an observational study, thus incurring several limitations. The selected dissemination strategy on social media and personal communications over email, direct message or telephone may have contributed to an ununiform accrual process. Various factors may potentially contribute to the observed gender and training status disparities, such as preexisting e-Learning platforms as well as familiarity with eL of participating vascular surgeons. Although the survey was designed to transparently and equitable reach broad communities of vascular surgeons internationally, selection bias and potential clustered data cannot be excluded. As the generated data and published results may be subject to debate, the EL-COVID is the first international study on vascular e-Learning of this size that fundamentally contributed to a better understanding of the contemporary needs of the vascular surgeon.